The piece was right in my area of interest and expertise (read rabid opinionatedness). I figured I could just write a review of the article which included my experience in why the cost of health care was so high which therefore drives the cost of health insurance, how new trends have made everything worse or different (AI, corporatization of medicine) and what could be done to nudge things in the right direction.
Unfortunately I will not be able to just jot off a short and informative post. The whole story is quite a bit more complicated. A little research has revealed to me my ignorance of some of the basic facts that are relevant to this question.
So, to start from the beginning, the US Congress has not voted to renew subsidies for insurance policies under the affordable care act. This means that many people who had received such subsidies will see their health insurance premiums increase significantly in 2026, which will lead many to drop their insurance and be unable to afford medical care.
But even that brief paragraph, which everyone I know believes is true and complete, is a misleading simplification.
The subsidies that haven't been renewed by Congress are actually enhanced subsidies, passed in 2021 in the height of the Covid pandemic as part of ARPA, the American Rescue Plan. They expanded help paying premiums to people making more than 4 times the federal poverty line and made some ACA insurance policies free for the poorest people. The initial bill was for only 2 years of this enhanced coverage and it has been extended now for 5 years. Enhanced subsidies led many people to get health insurance who hadn't been able to afford it. For some of them it was a dream. They were able to get low or no cost health insurance and thus receive healthcare that they had foregone for years. It was a delight to treat those patients who finally could do what we recommended they do, be it medication that worked better, procedures to make them more mobile or preventive care like cancer screening. But for many people health insurance was still really expensive.
It turns out that average out of pocket yearly premiums have not gone down since 2021, but they haven't gone up nearly as much as they would have, since the government subsidizes more of the cost. Lives were saved due to more people having access to care, but it could have been much better. Healthcare costs have increased but health insurance costs have outpaced them. It appears that the health insurance industry has taken advantage of higher subsidies to increase their income. Margins aren't higher, but costs associated with insurance continue to grow, so it does appear that subsidies subsidize consumers some but health insurance more.
Also there is the not-exactly-fraud but definitely shady business that always happens when there is lots of government money around. Health insurance brokers and salespeople make money off of selling people insurance and so they sell more insurance. Sometimes they sell insurance to people who don't use it and may not have actually participated in buying it. Agents' commissions eat up part of federal funding. The multitude of insurance companies and products that are part of our system make discovering what is going on much more difficult.
And, of course, there are the many issues that Zack Cooper mentions in his article. The American version of healthcare is terribly expensive. Causes of this include the fact that our costs for drugs is much higher than in markets outside of the US, we pay more for procedures (especially ones done in hospitals such as spinal surgery and joint replacements) and for office visits. It is difficult to find out how much anything costs or compare different options on price or quality within the US. This makes it very difficult for healthcare consumers to favor providers of inexpensive and high quality care. Competition, which might improve quality and costs, is not a feature of American healthcare.
Doctors are increasingly employed by corporations who try to get as many patient contacts out of them as possible, leading to worse care and referrals to consultants for things we used to deal with in primary care. We wanted to be employed, I recall, because it sounded more relaxing. We would not have to arrange for our own call schedules or fund capital outlays or deal with the ups and downs of take home pay which are inevitable when self employed. But now we are disempowered and more often burned out. So I think it wasn't a good trade.
I agree with Zack Cooper that the ACA subsidies aren't the answer to our problem. I also agree that they should be extended, but with some kind of strings attached to make sure that inflation of costs not directly related to patients receiving good quality care do not consume this money. Families and individuals are looking at significant increases in what they spend for health insurance if the enhance subsidies are not renewed. This will mean insurance is unaffordable and so healthy people will not buy it. Their costs when they do need to receive medical care will be so high that they will either forego that care and die or be unable to work, or get delayed extremely expensive care which will eventually be paid for by federal or state governments. Health insurance companies will suffer as the people they insure are sicker.
Phasing out subsidies will probably require regulation of healthcare costs and introduction of a public health insurance options such as Medicare which could compete with private companies. Price and quality transparency would help. The increasing corporate control of hospitals, doctors and clinics whose prime directive is making shareholders happy will make control of healthcare costs a moving target.
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